unlocking the secrets to motivational interviewing for ... the secrets to motivational interviewing...
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Unlocking the Secrets to Motivational Interviewing for Chronic Disease Prevention and Treatment
Rhonda DiNovo, LMSWClinical Assistant Professor, COSW
Today’s Learning Objectives
Intro to Motivational Interviewing: Brief History Theoretical Framework Definition Style Spirit Process and Techniques
The Basic Facts of Motivational Interviewing
• Founders: Dr. Miller & Stephen Rollnick, 1991• MI evolved from the addiction field, and now applies to numerous behavior
changes (ie. Mental health, co-occurring disorders, weight change and nutrition, HIV, medication adherence, gambling, smoking cessation, and non-clinical settings such as schools, universities, etc.
• MI is evidence-based, that is has been shown through research methodologies to be successful and replicable
• MI is designed to work fairly quickly, often requiring just 2 to 4 sessions, which makes it relatively fast acting and inexpensive.
• MI is NOT a form of cognitive-behavioral therapy, but rather a tool for addressing a problem and motivating change
• MI is NOT a therapeutic technique, but rather a conversational style(copyright, K. Sciacca, 2009)
New Material:Constructing a Theoretical Framework for MI
MI practice aligns with four foundational social work theories: • Person-Centered Approach: non-directive, empathic
approach that empowers and motivates • Self Determination Theory: examination of psychological
needs and continuum of motivation• Trans-theoretical Model of Change: understanding
fluctuations in and incremental stages of changes• Mindfulness: A state of active, open awareness and attention
on the present moment
Person-Centered Approach• Carl Rogers, American psychologist
and founder of humanistic theory (person-centered care)
• Miller and Rollnick’s Principles of Person Centered Care: The needs of our clients have
priority. Change is self change. Our
service is one of facilitation. People are their own experts. We don’t make change happen.
Change requires partnership. Motivation for change is not
installed, rather evoked. Clients make their own decisions.
• https://www.youtube.com/watch?v=XvO8tvrtOms
• https://www.youtube.com/watch?v=X6fidphMX38
• https://www.youtube.com/watch?v=xi76tmxEJig
Self Determination TheoryPeople have natural or intrinsic tendencies to behave in healthy & effective ways. Three psychological needs must be met:
• The need to be effective in dealing with environment
Competence
• The need to control the course of their lives
Autonomy
• The need to have close, affectionate relationships with others
Relatedness
SelfDeterminationTheory.org
The Self-Determination Continuum
A-Motivation Nonintentional, incompetence, lack of control
Ex-External Compliance, external rewards/punishment
Ex-Somewhat external Self-control, ego, internal rewards/ punishment
Ex-Somewhat internal Personal importance, conscious valuing
Ex-Internal Congruence, awareness, synthesis with self
In-Internal Interest, enjoyment, inherent satisfaction
Based on Ryan, R.M. & Deci, E.L. (2000). Self-Determination Theory & the Facilitation of Intrinsic Motivation, Social Development, and Well-Being. American Psychologist. 55(1), 68-78.
What regulates MOTIVATION?What’s the source?
Trans theoretical Model: Theory of Change
Pre-contemplatio
n
Contemplation
Preparation
Action
Maintenance
Go Back (Relapse)
No intention of changing behavior
Aware a problem exists, but no
commitment to action
Intent upon taking action
Actively modifying behavior
Sustained change –new behaviorreplaces old
Fall back into old patterns of behavior
Stable, safer lifestyle
Mindfulness Theory
Definition: A state of active, open
awareness and attention on the present moment.
Observation of thoughts and feelings from a distance, without judging them as good or bad.
We have thoughts, but we are not our thoughts.
Mindfulness Principles Live in the present, here-and-now moment. Engage fully in what you are doing rather than “getting lost” in your thoughts Consciously set intentions. They set the stage for what is possible and directly determine
outcomes. Experience awareness of here-and-now moments with openness, interest and receptiveness.
(In this way, even painful thoughts, feelings, sensations and memories can seem less threatening or unbearable)
Facilitate “being”, rather than “doing”. Be still and observe in a non-judging, non-striving way.
Allow your feelings to be as they are, let them come and go rather than trying to control them.
Become aware in four main areas: body (breath), feelings, mind (awareness, concentration), mind-object (what we think about).
Definition of Motivational Interviewing
• A collaborative conversation style for the primary purpose of strengthening a person’s own motivation and commitment to change
The Style of MI
• Not just techniques• A way of being present
with a person• A way of guiding
through communication• Approach the
relationship with exploration and wonder
The Spirit of MIHabits of the HeartWe are a privileged
witness to changeFour key elements• Partnership• Acceptance• Compassion• Evocation
PartnershipHow do you achieve this?- Practice self-awareness- Ask, don’t tell- Keep your “righting
reflex” in check
isWorking together
Showing interest and support
*Client centered
A waltz
is notDone by someone,
to someone
Persuasion and argument
About you (the facilitator)
A wrestling match
Motivational Interviewing, Miller & Rollnick
Acceptance
How do you achieve this?Demonstrate: Absolute Worth Accurate Empathy Autonomy Affirmation
is about
worth
autonomy
empathy
affirmation
is not about
approval of actions
acquiescence to status quo
Motivational Interviewing, Miller & Rollnick
CompassionWhat:• Seek and value the well being of another• Deserve the trust you been given
How do you achieve this? Actively promoting and
committing to the pursuit of another’s welfare
Giving priority to their needs
Evocation
How do you achieve this?Drawing out Evoking and
strengthening change motivations that are already within
isStrengths-
focused
Trusting the *client
Drawing water from the well
is notDeficit-focused
Believing you know best
Watering from a garden hose
Motivational Interviewing, Miller & Rollnick
The MI Process
Two phases:
• Engaging• Focusing1. Building motivation
• Evoking• Planning
2. Strengthening commitment to change
The four processes flow, overlap, and recur.
Process Step #1: Engagement
Establishment of mutual trust and respect
Agreement on treatment goals
Collaboration on mutually negotiated tasks to reach the goals
Technique for Engaging:Four Basic Listening Skills
OARS:• Open-ended questions• Affirming• Reflective Statements• Summarizing
Technique for Engaging: Utilizing OARS to Explore Values and Goals
Exploring client’s top 5-10 values is important/key to: Appreciating client’s internal frame of reference Knowing/utilizing what motivates client Promoting engagement Focusing and guiding their actions Reflecting on discrepancies and inconsistencies
Process Step #2: Focusing
• Clarifying, developing and maintaining a specific direction in the conversation about change
• Goals may/may not involve behavior change.
• Change can also occur in attitude, thoughts, acceptance of not change
Three Sources of Focus
• The client (presenting problem and concerns)
• The setting (agency is funded to address specific issues and provide certain services)
• The SW (own perceptions of the issues to address)
Technique for Focusing: Agenda Mapping
Agenda mapping involves a sequence of actions: Structuring Statement: “Would you mind if we
consider…”, “Can we take a moment to discuss…” Considering Options: list the options we might focus on
together Allow client to reflect on options, include affirmations,
invite new ideas, reflect, and include your opinions Zooming In: Consider priorities, urgent attention items,
limits to focus, negotiate best option Summarize: Wrap up by mentioning the big picture of
what you’ve considered together, then pinpoint one or two top priorities, remind client that we can return to the map when needed, and finish by asking for client’s response “what else?”
Technique for Focusing: Exchanging Information Utilizing Elicit-Provide-Elicit
• It’s unhelpful to provide info the client already has considered or tried
• EPE: the information is sandwiched between two questions of permission
• Respectful way to provide information that prevents you from telling client what they already know, which increases client’s willingness to listen
• Allows you to use the time wisely by providing them with info they do need/want to know, and allows client to decide
Technique for Focusing: Information Exchange Utilizing Elicit-Provide-Elicit
Elicit (Ask):• Ask permission, allow them to choose what to do or think, agree or disagree• Explore client’s prior knowledge, clarify information needs and gaps• Ask about their interest in whatever information you may be able to provide• Ask: May I….?, Would you like to know….?, Is there any info I can offer?, What
do you know about…..?
Provide (Tell):• Prioritize what information to provide• Give clear, manageable doses, Use every day language• Use autonomy-supportive language, Acknowledge freedom to disagree or ignore
Elicit (Ask):• Checking back in to inquire about their understanding, interpretation or
response to the info• Ask open-ended questions: What do you think about the information?, What do
you think you will do with the information?, How does this information relate to your situation?
• Reflect reactions: You seem surprised……, You look resolved……, You are thinking about something……
Process Step #3: Evoking
• Social worker elicits motivation for change through OARS
• Clients respond, and their own talk moves them into change
Evoking Part #1: Preparatory Change Talk
• Acronym: DARN• None of these, alone or together,
indicate that change in going to happen
D- Desire Statements• I want to make my life better.
A-Ability Statements• I can do it.
R-Reason Statements• Here are the reasons I have to
quit.N-Need Statements
• I need to do this.
Evoking Part #2: Mobilizing Change Talk
• Acronym: CAT• Committing language signals
likelihood of actionC-Commitment
• I will, I promise, I intend to, I guarantee
A-Activation• Language that describes
when and how the change will occur
T-Taking Steps• Speech that indicates
steps have been taken in the direction of change
Technique for Evoking: Decisional Balance • Ambivalence (mixed feelings
about change) is normal and necessary
• Ambivalence can be uncomfortable and complex
• Solution: Neutrality (not encouraging movement in a particular direction)
• Rather, explore both pros/cons of options in a balanced way
• https://www.youtube.com/watch?v=7vJ8jBqzVqU
Process Step #4: Planning
• Developing commitment to change and formulating a plan for action by elicitingthe client’s own solutions, promoting autonomy and strengthening change talk
Technique for Planning: Development
• With several clear options, task is to prioritize and choose
• Steps: (Path mapping/similar to agenda mapping)
• Confirm the goal• Itemize the options (ask
permission)• Elicit the client’s preferences
(explore pros/cons) • Summarize the plan• Troubleshoot
Technique for Planning: Implementation
• The plan is not a final step, but rather a beginning step
• Implementation (doing the plan) requires: – specificity (ready, willingness,
and ability to do)– intention (what, when, and
how is the reasonable next step?)
– Commitment (how will monitoring and support happen?
Technique for Planning: Supporting Change
• Assume: – Change is not linear, takes
time– Motivation and persistence
fluctuates– Setbacks occur
• Support persistence with MI spirit and style
• Flexible Revisiting– Re-planning– Reminding (re-evoking)– Re-focusing– Re-engaging
Five Questions for MI BeginnersWhy would you
want to make this change?
How might you go about it in order to
succeed?
What are the three best reasons for
you to do it?
How important is it for you to make this change, and
why?
So what do you think you’ll do?
… and your *client will feelEngaged. Empowered. Comfortable. Understood.
Motivational Interviewing, Miller & Rollnick
What changes might our clients consider?
If they want to keep smoking
If (or how) to break the news of their diagnosis to a
loved one
How much they drink on a nightly
basis
How to address tension with a family member
The amount of time or money they spend on
AOD
How many hours they dedicate to
exercise
Whether they want to go
through the treatment process
Addressing their weight issue
Whether or not they’re going to
take their medicine
Wrap Up: Questions & Answers
Rhonda DiNovo, LMSWPhone- (803)[email protected]